Clinical Documentation Tip: Atrial Fibrillation Freddy Santoso, CCS, CCDS

Definitions

Clinical Example – “Mr. Smith” HPI: 88 y M with h/o HTN, dysphagia admitted with dyspnea and productive cough. Overnight developed Afib with RVR P/E: Tachycardia to 140s Lab: EKG = Afib; CXR = RLL consolidation Rx: Antibiotics started on admit. Metoprolol, diltiazem, amiodarone bolus/gtt without good response x7 days; started apixaban; Cards consult - family declined any TEE/cardioversion or ablation as patient asymptomatic

Documentation Impact Aspiration PNA “AFib w/ RVR” POOR GOOD Aspiration PNA “AFib w/ RVR” filler filler filler fillerfi Expected Length of Stay = 3 Days Aspiration PNA Persistent Afib w/ RVR Expected Length of Stay = 5 Days

Clinical Example – “Mrs. Smith” HPI: 55 y F no significant PMH p/w SOB, chest tightness x 2 weeks. P/E: Tachycardia 140s-160s. BMI 44 Lab: EKG: Afib Rx: Metoprolol, diltiazem uptitrated to no effect; day #2 Cardiology consult; heparin started; underwent successful DC cardioversion day #4

Documentation Impact “Afib w/ RVR” “BMI 44” POOR GOOD “Afib w/ RVR” “BMI 44” Expected Length of Stay = 2 Days Persistent Afib Morbid obesity with BMI 44 Expected Length of Stay = 3 Days

Key Points Avoid “Afib” or “pAF” – nonspecific/ambiguous Use “paroxysmal” if < 7 days Use “persistent” if > 7 days or if > 48 hours + decision to cardiovert (electrically or pharmarcologically) Use “longstanding persistent” if > 12 months (not just ‘longstanding’)

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